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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT -------------------- -- (Complete in Triplicate) Permit No. - - -------- _ ___.____t__-____ This permit Expires 1 Year From bate Issued Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCA N ° �-------._. .------CENSUS TRACT --------------------- Owner's Name --------- ----------------- Phone - --------------- Address�. v_�'-_- - --- ' - __ . , 4 .- , {., ----- = { ---. --------- City ------= k"-- -------------••--------...... . r � Y - Contractor's Name . ----- -= =--: ---' ---------.License # _ r`-- ------- ----- Phona Installation will serve: Residence (] E%partment House❑ Commercial ❑Trailer Court ;❑ Motel ❑ Other _.____� Number of living units: --- I` ------ --- Number of bedrooms ______Garbage Grinder ___________ Lot Size ___!q ------------------------------------ Water ""''- ----------------------- Water Supply: Public System and name ________________________ ------------ .------ Private 25" Character of soil to a depthh of 3 feet: Sand ❑ Silt E] Gay ❑ Peat ❑ Sandy Loam ❑ Clay Loam CT - Hardpan r ❑ Adobe -❑ Fill Material ___________ If yes, type ------------ _________ (Plot plan, showing size ;I'lof lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION: (No septic tank or see age pit permitted if public sewer is available within 200 feet,) \ PACKAGE TREATMENT (I SEPTIC TANK � j%p Ifs f * �' ` ` Size ... -_ Liquid Depth-�------- Clapacity -ip C_ Type c.�_--- Material ___� _.:.__ No. Compartments _____------- _---- dlistance to nearest: Well---------:�$__/----------------- Foundation ------------ Prop. Line---F--------------- LEACHING LINE [" No. of Lines ______________________ Length of each line_____--__ 4_--__u._.____-- Total Length -------------- D' Box ............ Type Filter Material ____ _______Depth Filter Material --- .__I-f-...- bistance to nearest: Well _____--5a__�________ Foundation ------ -_______ Property Line _ _ C _.___. -- SEEPAGE PIT [� Depth _______. _ Diameter _�_+�7___p-_.__ Number -.------/ ----------- ------ -- Rock Filled Yes ��__N_o i❑ Water Table Depth -----------4!--------------------------------- Rock Size __ 1 ....... i Distance to nearest: Well--------------Q---•-----------------Foundation---------1-_P----. Prop, Line ------ ��.�_...___.-.. I -- REPAIR/ADDITION (Prev. Sanitation Permit # -------------------------------------------- Date _______-________- Septic Tank (Specify Requirements) ------------------- --------------- Disposal Field (Specifyi Requirements) ------------------------------------------------------------------------------------------------------------------------ i ------------------------------------------,----------- -- -------------------------- --------------------------------------------------------------------------------------- (Draw existing and required addition on reverse side) I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, State!lLaws, and Rules and Regulations of the San Joaquin local Health District. Home owner or licen- sed agents signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to Workman's Corhpensation laws of California." Signed--------- ---------------------- ' - wne B--------- - Lli�� Y -------- ---- ---{If other than ow------- �I� ��Title .._w�-r.��a- R .D ARTMENT USE ONLY APPLICATION ACCEPTED �BY --_ __ --- _______ BUILDING PERMIT ISSUED ADDITIONAL COMMENTS:__________________ - --- ------------- -- --- ------ ---- ------ -I Final b Inspection p Y G- �- ------------------------------------------------------------------------------ SAN JOAQUIN LOCAL. HEALTH DISTRICT E. H. 9 1-'6$ Rev. 5W -----. DATE �r -------DATE-------------- ------------ ,� .Date ?�